Committee: Discipline
Decision Date: 27 Jul 2016
Summary:
On July 27, 2016, the Discipline Committee of the College of Physicians and Surgeons of Ontario found that Dr. Ali Ali Abdulla Mansour has committed an act of professional misconduct in that he has engaged in an act or omission relevant to the practice of medicine that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable, or unprofessional and in that he has failed to maintain the standard of practice of the profession.
Dr. Mansour, a family physician, practised at the Parliament Walk-In Clinic located at 1 Oak Street in downtown Toronto, Ontario (the “Clinic”).
On July 30, 2013, the College received an anonymous call from a physician who indicated she had concerns with Dr. Mansour’s use of a PA, namely, that a PA was seeing and treating patients without proper supervision, while Dr. Mansour was not in the clinic and was in fact on vacation.
The College launched a section 75(1)(a) investigation into Dr. Mansour’s practice in August 2013 after receiving this information.
On August 14, 2013, representatives of the College attended unannounced at the Clinic and spoke with the receptionist, the PA, and the Clinic Manager. Dr. Mansour was not present.
The receptionist said Dr. Mansour was away for a month and that Dr. Mansour’s PA was seeing patients with no physician on the premises. The PA initially denied any knowledge of Dr. Mansour being out of the country on vacation, saying she understood Dr. Mansour was not in the clinic that day because he was home sick.
Once the PA was told that the College understood Dr. Mansour was away, the PA said Dr. Mansour was in Libya and had been gone for a month. The PA also said that she was working on her regularly scheduled days in Dr. Mansour’s absence, and did not work under the supervision of any other physician. She worked only under the supervision of Dr. Mansour. She stated that she communicated electronically with Dr. Mansour about any difficult cases. The PA confirmed Dr. Mansour had remote access to the patient records and could look at them (with the exception of lab results) and discuss the plan with her. If she was ordering medication, she would enter the medications into the electronic record and print it out, then use a stamp of Dr. Mansour’s. She would not prescribe narcotics or controlled drugs. Some of the patients she would see were walk- in patients and did not have an established physician-patient relationship with Dr. Mansour.
Around August 14, 2013, Dr. Mansour spoke on the telephone with a College representative and said that he was sick and therefore had been unable to go to work that day. Dr. Mansour states that this telephone conversation took place after Dr. Mansour spoke with the Clinic Manager, during which the Clinic Manager advised Dr. Mansour he ought not to have let the PA see patients in his absence, among other things. Dr. Mansour states that he panicked and told the College representative he was not at the Clinic because he was sick. In actuality, Dr. Mansour was out of the country at that time.
On March 26, 2014, the College requested various documents and information pertaining to when Dr. Mansour was on vacation/out of the country, where he was during that period, and copies of any supporting documentation, as well as dates when the PA worked at the clinic and information about what Dr. Mansour billed OHIP during that period from Dr. Mansour’s counsel.
Dr. Mansour advised the College he was checking his records regarding where he was in July and August of 2013, and whether bills were submitted to OHIP during this time period, and would write again once this information had been compiled.
On May 13, 2014, Dr. Mansour told the College he had not found any records documenting where he was in July and August of 2013, and that his recollection was that he was in Libya from July 3 to 8, 2013, and in Turkey from August 9 to 15 or 16, 2013. He told the College that his PA worked at the clinic for 3 days in July and 4 days in August while he was away. Dr. Mansour further advised he was in Turkey when he spoke with the College representative on August 14, 2013, that he had “panicked and spoke without thinking first” and that he “is very anxious about this issue and until now has not known how to make things right.”
Dr. Mansour also told the College that he billed OHIP when he was out of the country and his PA was seeing patients, should not have done so, and was conducting a self-audit of these amounts in order to repay OHIP.
On May 23, 2014, the College wrote to Dr. Mansour’s counsel requesting clarification about where Dr. Mansour was between July 9 and August 8, 2013. On June 3, 2014, Dr. Mansour’s counsel told the College that Dr. Mansour was in Ontario between July 9 and August 8, 2013 and was in Toronto on any day on which he was scheduled to work during that time period.
The College then asked Dr. Mansour to attend at the College with his passport and any other supporting documents to verify he was in Ontario between July 9 and August 8, 2013. The College sent a further letter dated July 24, 2014, requesting confirmation of a date upon which Dr. Mansour could attend the College, and a further request on August 7, 2014.
Dr. Mansour’s counsel wrote to the College on August 7, 2014, saying that Dr. Mansour was in Libya and his return to Canada had been delayed. Counsel advised Dr. Mansour would not be in a position to provide the requested documents until his return, which was expected on August 10, 2014. Counsel further advised dates upon which Dr. Mansour was available to attend at the CPSO for an interview by the Medical Inspector.
Dr. Mansour’s counsel told the College in an August 14, 2014 letter that Dr. Mansour had had to surrender his Libyan passport (which he used for his trip in July/August 2013) when he changed to a Canadian passport. Counsel also provided the billing and medication records requested by the College.
Dr. Mansour’s counsel told the College in a September 22, 2014 letter that the information previously provided to the College by Dr. Mansour was incorrect in the following ways: i) Dr. Mansour had not surrendered his Libyan passport; and ii) Dr. Mansour was in Libya and Turkey continuously between July 5 and August 15, 2013, returning to Canada on August 16, 2013. He was not in Ontario between July 9 and August 8, 2013 as previously advised. Enclosed with the letter was a copy of Dr. Mansour’s Libyan passport used in 2013. Dr. Mansour apologized through his counsel for having provided inaccurate information in the past and indicated that, having now shared the information about his whereabouts, he was eager to fully cooperate with the College’s investigation.
The College interviewed the PA, who confirmed she saw patients at the Clinic without Dr. Mansour being present, at his request. The PA advised she initially worked under verbal orders from Dr. Mansour, and that she created Medical Directives later, and sent them to the Clinic for its use. Dr. Mansour confirms this is true.
The PA had graduated from a PA program at McMaster University in 2012, and started working with Dr. Mansour, in about May, 2013. Dr. Mansour spent a couple of weeks seeing patients with her, assessing her skills, and discussing cases and patient management with her in breaks between seeing patients.
The PA told the College that Dr. Mansour personally asked her to see patients when he was not there.
When Dr. Mansour was away in July and August 2013, he directed the PA to contact him if she needed him. The PA told the College that at no time did Dr. Mansour discourage the PA from contacting him to discuss patient care and that she was usually able to reach him.
After a self-audit, Dr. Mansour repaid $16,734.32 to the Ministry of Health and Long-Term Care in respect of billings made in relation to patient visits in the months of July and August 2013, where the patients were seen by the PA but not by Dr. Mansour.
STANDARD OF PRACTICE
A College-retained expert opined that Dr. Mansour failed to meet the standards of practice in the following respects:
- His use of a PA fell below the standard of care in respect of 19 patients, primarily with respect to supervision and delegation. The criteria for delegation were met in only one chart. These deficiencies could expose his patients to harm.
- His medical documentation fell below the standard of care in respect of 15 to 17 patients. In some cases, there were notes which appeared to be copied and pasted in patient charts.
- The care provided demonstrated concerns about his knowledge and judgment in almost all charts reviewed. In various files, this related to one or more of timely or appropriate follow-up of abnormal test results, lack of knowledge of current guidelines, and over-
extensive investigations without apparent clinical reasoning documented or explained.
Dr. Mansour responded to the expert’s report and said that he had not used a PA in his practice since these issues arose in August 2013. Dr. Mansour told the College that he has since completed the U of T medical record keeping course and had become more comfortable with the Clinic’s EMR system. He told the College that, in response to Dr. Walker’s concerns about his knowledge of various guidelines, Dr. Mansour reviewed five CPSO policies, as well as a number of clinical guidelines. Dr. Mansour also told the College had registered to take a course on diabetes management and a review course in internal medicine and had performed a self-audit and repaid to OHIP the amounts he billed during the times he was not present at the Clinic. Dr. Mansour completed the Medical Record Keeping course at the University of Toronto in November 2014.
PENALTY AND COSTS
The Committee ordered and directed that:
Dr. Mansour to appear before the panel to be reprimanded.
- The Registrar suspend Dr. Mansour’s certificate of registration for a period of nine (9) months commencing immediately.
- The Registrar to place the following terms, conditions and limitations, effective immediately, on Dr. Mansour’s certificate of registration:
Restriction
(a) Dr. Mansour shall not delegate any acts or any care of any patients to any unregulated health professional.
Education
(b) Dr. Mansour shall, at his own expense, participate in and successfully complete the following educational courses:
i. Ontario College of Family Physicians course entitled “Practising Wisely” within six months from the date of this order; and
ii. Individualized instruction in ethics approved by the College at the instructor’s earliest availability. Dr. Mansour will provide proof of successful completion within three (3) weeks of completing the instruction. The instruction will involve one-on-one sessions with a College-approved instructor, incorporating principles of guided reflection, tailored feedback, and other modalities customized to the specific needs of Dr. Mansour as assessed by the instructor. The instructor will report to the College regarding Dr. Mansour’s progress and compliance.
Clinical Supervision & Re-Assessment
(c) Dr. Mansour shall retain a clinical supervisor, approved by the College, who will sign an undertaking in the form attached hereto as Appendix “A” (the “Supervisor”) no later than 30 days prior to Dr. Mansour’s return to practice after the suspension referred to in paragraph 4 above. Dr. Mansour shall practice under the guidance of the Supervisor for a period of six (6) months. Dr. Mansour shall meet with the Supervisor monthly to discuss any concerns related to patient care.
(d) Within six (6) months after the completion of the Clinical Supervision, Dr. Mansour will submit to a reassessment of his practice (the “Reassessment”) by an assessor or assessors selected by the College (the “Assessor(s)”). The Reassessment may include a chart review, direct observation of Dr. Mansour’s care, interviews with colleagues and co-workers, feedback from patients and any other tools deemed necessary by the College. The Reassessment shall be at Dr. Mansour’s expense and he shall co-operate with all elements of the Reassessment. Dr. Mansour shall abide by all recommendations made by the Assessor(s) subject to paragraph (e) below, and the results of the Reassessment will be reported to the College and may form the basis of further action by the College.
(e) If Dr. Mansour is of the view that any of the Assessor(s)’s recommendations are
unreasonable, he will have fifteen (15) days following his receipt of the recommendations within which to provide the College with his submissions in this regard. The Inquiries Complaints and Reports (“ICR”) Committee will consider those submissions and make a determination regarding whether the recommendations are reasonable, and that decision will be provided to Dr. Mansour. Following that decision Dr. Mansour will abide by those
recommendations of the Assessor(s) that the ICR Committee has determined are reasonable.
Other
(f) Dr. Mansour shall submit to, and not interfere with, unannounced inspections of his practice location(s) and and to any other activity the College deems necessary in order to monitor his compliance with the provisions of this Order.
(g) Dr. Mansour shall comply with the College Policy on Practice Management Considerations for Physicians Who Cease to Practise, Take an Extended Leave of Absence or Close Their Practice Due to Relocation in respect of his period of suspension, a copy of which forms Appendix “B” to this Order.
(h) Dr. Mansour shall inform the College of each and every location where he practices, in any jurisdiction (his “Practice Location(s)”) within fifteen (15) days of this Order, and shall inform the College of any and all new Practice Locations within fifteen (15) days of commencing practice at that location, until the report of the assessment of his practice have been reported to the College.
(i) Dr. Mansour shall consent to the College making appropriate enquiries of the Ontario Health Insurance Plan and/or any person who or institution that may have relevant information, in order for the College to monitor his compliance with this Order.
(j) Dr. Mansour shall be responsible for any and all costs associated with implementing the terms of this Order.
- That Dr. Mansour to pay to the College costs in the amount of $5,000.00, within 30 days of the date of this Order.